Drug policy debate is needed
This year marks the 100th anniversary of the signing of the International Opium Convention, the first legal instrument on international drug control. In recent weeks the 55th session of the Commission on Narcotic Drugs—the policy setting body of the United Nations on drug control matters that is composed of 53 member states—was held in Vienna[1]. It adopted 12 resolutions, including ones on the treatment, rehabilitation, and social reintegration of drug dependent prisoners, treatment as an alternative to imprisonment, and the prevention of death from overdose. Yury Fedotov, executive director of the UN Office on Drugs and Crime, emphasised the prioritisation of the health agenda, stating: “At present, the balance between our work on the supply and demand sides stays firmly in favour of the supply side. We must restore the balance. Prevention, treatment, rehabilitation, reintegration, and health have to be recognised as key elements in our strategy.”[2]
This recent emphasis on health is welcome, because discussions on drug policy are too often dominated by criminal justice arguments and polarised opinions on how to solve the so called war on drugs. Indeed, it is hard to maintain a neutral position on this topic, and any argument in favour of reviewing current policy in the light of existing evidence is in danger of being portrayed in the media as championing the legalising of all drugs, inciting headlines of the “top doc drug shock” variety. This also makes it difficult for national governments to advocate a shift in policy. It is worthy of note that the supporters of drug reform listed on the Transform Drug Policy Foundation website include the current UK prime minister and his deputy, who offered their support while in opposition, although their appetite for reform may have since diminished.[3]
The proportion of adults aged 16-59 in England and Wales who report recent use of illicit drugs fell from 11.1% in 1996 to 8.6% in 2009. This reduction is mainly the result of a drop in cannabis use, and the proportion of problem drug users, including those who inject, has risen slightly in the past four years to 2% of 25-34 year-olds.[4] In addition, cocaine use continues to increase. But it is the global picture of multibillion dollar organised crime and the subjugation and virtual destruction of whole countries in Central America and South America that makes evidence based international action urgent. It is possible that the harm caused by drug policy might exceed that from the drugs themselves. The presidents of Costa Rica, Guatemala, El Salvador, Colombia, and Mexico have said in recent weeks that they wish to open up discussions on legalising drugs, forcing a reluctant US Vice President Biden to meet them.
What would drug reform look like? Most serious commentators call for decriminalisation—that is, downgrading of the status of personal drug use—so that using drugs is not a crime or is a lesser one. The aim is to prioritise health considerations over criminal ones in personal users, but with the secondary goals of reducing criminal behaviour and improving the health of the population. This is not the same as legalising drugs.
However, it is difficult for countries to act alone to decriminalise drug use while the 1961 UN Single Convention on narcotic drugs remains in force: the Beckley Foundation in England has set up a global initiative for drug policy reform to draft a fresh UN convention that would allow signatory countries more freedom in deciding their own national drug policies (www.beckleyfoundation.org).
What problem might decriminalisation solve and what is our legitimate interest as clinicians? It is important to distinguish the damage that drug use causes to individuals from its wider societal harms, but both have an impact on public health. The problems we see in our acute hospitals arise more from infected needles, contaminated drug supplies, and the consequences of social exclusion than from the drugs themselves. Prison health is dominated by drug misuse. A survey of 1500 prisoners in 2005-6 found that nearly 80% had a history of illicit drug use at some time in their life.5 A national survey in 1997 found that a quarter of heroin users started using the drug in prison. The criminalisation of drugs damages families and communities in a way that is not confined to the impact of crime, and it has far reaching health consequences.
What can we learn from other countries? Those on both sides of the argument will marshal statistics from countries such as Portugal and the Netherlands. However, a UK trial of a non-punitive and supportive approach to recidivist heroin injectors has shown that the supply of clean drugs and equipment under supervision can improve individual health, wellbeing, and social integration.[6]
Why should we look again at UK policy now? The present government has taken a brave policy approach to alcohol and tobacco in the interests of the nation’s health, and a review of drug policy is timely from several perspectives alongside the Commission on Narcotic Drugs meeting in Vienna. The Liberal Democrat Party voted overwhelmingly at its conference last autumn to set up a panel to consider decriminalising all drugs, which makes it official party policy, and there is support for decriminalisation from the all party parliamentary group on drug reform.[7] The home affairs select committee is also currently considering drug policy.[8] As well as their responsibility to individual patients, doctors have a collective responsibility to encourage a rational debate on how best to minimise harm to the health of the population through advocating evidence based policies, and this evidence in the field of illicit drugs has recently been clearly laid out by Strang and colleagues.[9] Government may not welcome this debate, but the potential health gain is great and doctors should support it.
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